Should doctors write job prescriptions?

Last month, news of Hawaii’s homeless challenge gained national attention on HBO’s Vice News (Hawaii News Now, 3/30/17). The 5-minute segment spotlights that “Hawaii legislators are debating whether to classify homelessness as an illness and housing as a treatment. (via HBO).” This Vice News report is not the kind of attention that Hawaii wants, but maybe it’s the attention that Hawaii needs.

Correspondent Caroline Modarressy-Tehrani interviewed four people to get their perspectives on the proposal to redefine homelessness as a medical condition. Gary Grinker, who is chronically homeless and has a heart condition; he visited the emergency room 241 times in 2016, costing taxpayers $1.2 million in healthcare. Senator Josh Green, who introduced a bill to redefine chronic homelessness as a disease and allow doctors to write prescriptions for housing. Representative Bob McDermott, who believes that Hawaii has “turned the safety net into a hammock.” And Dr. Daniel Cheng, an emergency room doctor at Queen’s Medical Center, which handles two-thirds of all homeless encounters in Hawaii.

I had three successive reactions to the news report.

First, doctors’ first responsibility is to take care of patients’ physical and mental health. A “prescription” for housing would probably involve time filling out forms and coordinating with social workers – time that doctors need to help patients.

Second, having a home may not make people more responsible for their health or reduce emergency room visits. It may even exacerbate health conditions, if people have health emergencies in their home and are unable or unwilling to seek help.

Third, if a solution to rising healthcare costs and chronic disease were housing, we would have more people living in shelters and healthier people at home. But in Hawaii, an alarming 82% of adults have at least one chronic disease or condition and 53% have two or more chronic diseases (heart disease, heart attack, stroke, diabetes, asthma, disability, cancer, chronic obstructive pulmonary disease, high blood pressure, high blood cholesterol, or obesity), according to the Department of Health’s “Chronic Disease Disparities Report 2011: Social Determinants.”

“Work is at the very core of contemporary life for most people, providing financial security, personal identity, and an opportunity to make a meaningful contribution to community life,” according to the National Alliance for the Mentally Ill (NAMI) factsheet, “Facts about mental illness and work” (1999).

A job gives people dignity as well as a paycheck. Doctors can assess a person’s physical and mental ability to work, and offer a referral to an employer – who could assess their skills, experience, and trustworthiness.

Do you think that we can reduce healthcare costs by prescribing housing? Could having a job help people be healthier?

2 Comments on “Should doctors write job prescriptions?”

Actually, according to the 2015 Homeless Service Utilization Report done by the UH Center on Family, “Among the 4,005 new adult clients who sought shelter and outreach services, one in five (19.6%) were employed.” While that percentage is better than some areas in the U.S., the obvious difficulty is keeping employment when you can’t get sleep, stay out of the elements, keep fresh food, bathe regularly, etc. Senator Dr. Josh Green sees all the aspects necessary for health and gainful employment may be to include living in housing as important as prescribing medicine. Perhaps, it will open more agile avenues for funding through insurance rather than just the overburdened bureaucracy of government grants and aid.

Some of the chronically homeless (“hard to house” and repeated instances of homelessness over a lifetime) that move into the Housing First program actually move into their own apartments and still live in their tents inside the apartment or can have all their hoarded belongings with them, or even hoard more. Eventually, however, with wrap-around supportive care, they do assimilate into their new home environment. That, to me, indicates a reasonable degree of mental illness and personal hygiene issues that needs to be addressed before employment is offered as a solution. Aside from decent paying employment being already difficult to find in Hawaii with the high cost of living, any challenges or barriers to success could seem insurmountable.

Many people are unhealthy due to heredity, or environmental stress such as employment or family issues, and these pre-existing conditions exacerbated or accelerated by homelessness. Housing helps to bring stability onto which other foundational aspects for living thrive. Temporary or transitional shelters are not substitutes for permanent housing and should not be looked at as a “one-stop solution” for all homeless individuals. It is a drastic change from living independently to living in a warehouse with absolutely no privacy. I understand why the homeless prefer living outdoors on their own to living in a shelter community with strangers. I can’t say that I wouldn’t do the same.

Life is a challenging and delicate balancing act requiring all the pieces to be in place and maintained. If the basics of shelter, food, water, air and sleep are not in place, then anyone could easily find themselves in crisis.

Hi Tisha, I appreciate your thoughtful comments. I haven’t read the Homeless Service Utilization Report and didn’t know that almost 20% of the homeless in Hawaii have a job. My perspective is that affordable housing may not be readily available, but a job that pays a small wage, daily or weekly, could make a difference immediately, at least for the other 80%. Thank you for reading Better Hawaii! aloha, Rachelle